Apilimod compositions and methods of use

ABSTRACT

Provided are compositions and methods related to the use of apilimod alone or in combination with glutamatergic agents or other agents for treating neurological diseases and disorders, and for the treatment of cancer.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation-in-part of U.S. patent application Ser. No. 17/862,471 filed on Jul. 12, 2022, which is a continuation of U.S. patent application Ser. No. 16/987,542, filed Aug. 7, 2020, now U.S. Pat. No. 11,439,649, which is a continuation of U.S. patent application Ser. No. 16/280,106, filed Feb. 20, 2019, now U.S. Pat. No. 10,751,345, which claims priority to U.S. Provisional Application Ser. No. 62/633,335, filed on Feb. 21, 2018, the contents of each are hereby incorporated by reference in their entirety.

FIELD OF THE DISCLOSURE

The present disclosure relates to compositions and methods using apilimod for use alone or in combination with glutamatergic agents in the treatment of neurological diseases and disorders and cancer.

BACKGROUND OF THE DISCLOSURE

Apilimod, also referred to as STA-5326, hereinafter “apilimod”, is recognized as a potent transcriptional inhibitor of IL-12 and IL-23. See e.g., Wada et al. Blood 109 (2007): 1156-1164. IL-12 and IL-23 are inflammatory cytokines normally produced by immune cells, such as B-cells and macrophages, in response to antigenic stimulation. Autoimmune disorders and other disorders characterized by chronic inflammation are characterized in part by inappropriate production of these cytokines. In immune cells, the selective inhibition of IL-12/IL-23 transcription by apilimod was recently shown to be mediated by apilimod's direct binding to phosphatidylinositol-3-phosphate 5-kinase (PlKfyve). See, e.g., Cai et al. Chemistry and Biol. 20 (2013):912-921. PlKfyve plays a role in Toll-like receptor signaling, which is important in innate immunity.

Some neurodegenerative diseases result in the accumulation of protein aggregates or other intermediates of cellular catabolism that may lead to neural toxicity and degeneration.

Glutamate, also referred to as glutamic acid, is the main excitatory neurotransmitter in humans. It is also a substrate in the synthesis of the main inhibitory neurotransmitter, GABA (γ-Aminobutyric acid), which regulates neuronal excitability.

Glutamate transporters are a family of neurotransmitter transporter proteins that move glutamate across neural cell membranes. Glutamate transporters include two main classes, the excitatory amino acid transporters and the vesicular glutamate transporters. The amino acid transporters remove glutamate from the synaptic cleft by stimulating reuptake into neural cells. The vesicular transporters move glutamate intracellularly from the cell cytoplasm into synaptic vesicles.

Glutamate excitotoxicity refers to a pathological process by which neural cells are damaged or destroyed by excessive glutamate stimulation. High levels of glutamate cause the over-stimulation of glutamate receptors such as the N-methyl-D-aspartate (NMDA) and AMPA receptors, setting in motion the pathological activation of various intracellular enzymes that results in damage to cellular structures including the cytoskeleton, membranes, and even DNA.

Glutamate excitotoxicity is implicated in various neurological diseases and disorders including spinal cord injury, stroke, and traumatic brain injury, as well as in certain neurodegenerative diseases of the central nervous system including multiple sclerosis, Alzheimer's disease, amyotrophic lateral sclerosis (ALS), Parkinson's disease, alcoholism or alcohol withdrawal and Huntington's disease.

SUMMARY OF THE DISCLOSURE

In one embodiment, the present disclosure provides a method of reducing neuromuscular degradation, reducing motor dysfunction, reducing deterioration of muscle strength, reducing deterioration of fine motor skills, maintaining fine motor skills, and/or improving muscle strength in a patient with a neurological disease or disorder.

In one aspect, the method includes administering to the patient, an effective amount of apilimod, or a pharmaceutically acceptable salt thereof, thereby reducing neuromuscular degradation, reducing motor dysfunction, reducing deterioration of muscle strength, reducing deterioration of fine motor skills, maintaining fine motor skills, and/or improving muscle strength in the patient. In one aspect, the apilimod salt is apilimod dimesylate.

In one aspect, the apilimod is administered at a dose of about 75 mg to about 150 mg twice daily (BID). In one aspect, the apilimod is administered at a dose of about 125 mg BID two times a day. In one aspect, the apilimod is administered at a dose of about 100 mg two times a day (BID). In one aspect, the apilimod is administered at a dose of about 75 mg BID two times a day. In one aspect, the apilimod, or a pharmaceutically acceptable salt thereof is in an oral dosage form or an orally disintegrating dosage form.

In one aspect, the neurological disease or disorder is selected from amyotrophic lateral sclerosis (ALS), Alzheimer's disease, attention deficit hyperactivity disorder, autism, cerebellar ataxia, Charcot-Marie-Tooth disease, Creutzfeldt-Jakob disease, dementia, frontotemporal dementia, epilepsy, Friedreich's ataxia, Huntington's disease, multiple sclerosis, obsessive compulsive disorder (OCD), Parkinson's disease, Progressive Supranuclear Palsy (PSP), Rett syndrome, senile chorea, spinal ataxia, spinal cord injury, and/or traumatic brain injury.

In one aspect, the method of the disclosure further includes administering an effective amount of a glutamatergic agent or an antioxidant. In one aspect, the glutamatergic agent is selected from a glutamate transporter modulating agent and a glutamate receptor antagonist. In one aspect, the glutamate transporter modulating agent is an excitatory amino acid reuptake inhibitor. In one aspect, the glutamate receptor antagonist is an N-methyl-D-aspartate (NMDA) receptor antagonist.

In one aspect, the glutamate receptor antagonist is selected from AP5 (R-2-amino-5-phosphonopentanoate), AP7 (2-amino-7-phosphonoheptanoic acid), CNQX (6-cyano-7-nitroquinoxaline-2,3-dione), CPPene (3-[(R)-2-carboxypiperazin-4-yl]-prop-2-enyl-1-phosphonic acid), NBQX (2,3-dihydroxy-6-nitro-7-sulfamoyl-benzo[f]quinoxaline-2,3-dione), and selfotel (CGS-19755). In one aspect, the glutamate receptor antagonist is selected from amantadine, atomoxetine, AZD6765, agmatine, gacyclidine, ketamine, memantine, eliprodil, and delucemin. In one aspect, the glutamatergic agent is selected from BHV-5000, lamotrigine, lanicemine, riluzole, trigriluzole, and topiramate. In one aspect, the antioxidant is edaravone, vitamin E, vitamin C and/or beta-carotene.

The present disclosure provides methods for treating a neurological disease or disorder and methods for treating cancer in a subject in need thereof, the method comprising administering to the subject a pharmaceutical composition comprising apilimod, or a pharmaceutically acceptable salt thereof, in combination with a glutamatergic agent.

In embodiments, the disclosure provides a method for treating a neurological disease or disorder in a subject in need thereof, the method comprising administering to the subject a pharmaceutical composition comprising apilimod, or a pharmaceutically acceptable salt thereof, in combination with a glutamatergic agent. In embodiments, the apilimod is apilimod dimesylate. In embodiments, the glutamatergic agent is selected from a glutamate transporter modulating agent and a glutamate receptor antagonist. In embodiments, the glutamate transporter modulating agent is an excitatory amino acid reuptake inhibitor. In embodiments, the glutamate receptor antagonist is an N-methyl-D-aspartate (NMDA) receptor antagonist. In embodiments, the glutamate receptor antagonist is selected from AP5 (R-2-amino-5-phosphonopentanoate), AP7 (2-amino-7-phosphonoheptanoic acid), CNQX (6-cyano-7-nitroquinoxaline-2,3-dione), CPPene (3-[(R)-2-carboxypiperazin-4-yl]-prop-2-enyl-1-phosphonic acid), NBQX (2,3-dihydroxy-6-nitro-7-sulfamoyl-benzo[f]quinoxaline-2,3-dione), and selfotel (CGS-19755). In embodiments, the glutamate receptor antagonist is selected from amantadine, atomoxetine, AZD6765, agmatine, gacyclidine, ketamine, memantine, eliprodil, delucemin. In embodiments, the glutamatergic agent is selected from BHV-5000, lamotrigine, lanicemine, riluzole, trigriluzole, and topiramate. In embodiments, the pharmaceutical composition is an oral dosage form, orally disintegrating form or a sublingual dosage form. In embodiments, the glutamatergic agent is administered in the same or a different dosage form as the apilimod.

In embodiments, the neurological disease or disorder is selected from Alzheimer's disease, amyotrophic lateral sclerosis (ALS), attention deficit hyperactivity disorder, autism, cerebellar ataxia, Charcot-Marie-Tooth disease, Creutzfeldt-Jakob disease, dementia, epilepsy, Friedreich's ataxia, Huntington's disease, multiple sclerosis, obsessive compulsive disorder (OCD), Parkinson's disease, Progressive Supranuclear Palsy (PSP), Rett syndrome, senile chorea, spinal ataxia, spinal cord injury, traumatic brain injury.

In embodiments, the neurological disease or disorder is dementia. In embodiments, the dementia is selected from AIDS dementia complex (ADC), dementia associated with Alzheimer's disease (AD), dementia pugilistica, diffuse Lewy body disease, frontotemporal dementia, mixed dementia, senile dementia of Lewy body type, and vascular dementia.

In certain embodiments for the treatment of frontotemporal dementia or ALS, the patient in need of treatment of is one having repeat expansions in the C9ORF72 gene.

In embodiments, the neurological disease or disorder is amyotrophic lateral sclerosis (ALS).

In embodiments, the neurological disease or disorder is Rett syndrome.

In embodiments, the neurological disease or disorder is obsessive compulsive disorder (OCD).

In embodiments, the subject is human.

The disclosure also provides a method for treating amyotrophic lateral sclerosis (ALS) in a subject in need thereof, the method comprising administering to the subject a pharmaceutical composition comprising apilimod, or a pharmaceutically acceptable salt thereof, in combination with a glutamatergic agent selected from riluzole and trigriluzole.

The disclosure also provides a method for treating Alzheimer's disease in a subject in need thereof, the method comprising administering to the subject a pharmaceutical composition comprising apilimod, or a pharmaceutically acceptable salt thereof, in combination with a glutamatergic agent selected from riluzole and trigriluzole.

The disclosure also provides a method for treating obsessive compulsive disorder (OCD) in a subject in need thereof, the method comprising administering to the subject a pharmaceutical composition comprising apilimod, or a pharmaceutically acceptable salt thereof, in combination with a glutamatergic agent selected from riluzole and trigriluzole.

The disclosure also provides a method for treating Rett syndrome in a subject in need thereof, the method comprising administering to the subject a pharmaceutical composition comprising apilimod, or a pharmaceutically acceptable salt thereof, in combination with a glutamatergic agent selected from BHV-5000, and lanicemine.

The disclosure also provides a method of treating cancer in a subject in need thereof, the methods comprising administering to the subject a pharmaceutical composition comprising apilimod, or a pharmaceutically acceptable salt thereof, in combination with a glutamatergic agent selected from riluzole and trigriluzole, preferably trigriluzole. In embodiments, the cancer is selected from brain cancer, breast cancer, cervical cancer, colorectal cancer, leukemia, lung cancer, lymphoma, melanoma or other skin cancer, ovarian cancer, prostate cancer, renal cancer, and testicular cancer.

The disclosure also provides a pharmaceutical composition comprising apilimod for use in combination therapy with a glutamatergic agent in the treatment of a neurological disease or disorder, or for the treatment of cancer. In embodiments, the apilimod is apilimod dimesylate. In embodiments, the glutamatergic agent is selected from a glutamate transporter modulating agent and a glutamate receptor antagonist. In embodiments, the glutamate transporter modulating agent is an excitatory amino acid reuptake inhibitor. In embodiments, the glutamate receptor antagonist is an N-methyl-D-aspartate (NMDA) receptor antagonist. In embodiments, the glutamate receptor antagonist is selected from amantadine, atomoxetine, AZD6765, agmatine, gacyclidine, memantine, eliprodil, delucemin. In embodiments, the glutamatergic agent is selected from riluzole, trigriluzole, BHV-5000, and lanicemine. In embodiments, the apilimod and the glutamatergic agent are contained in the same dosage form.

In embodiments, the pharmaceutical composition is for use in treating a neurological disease or disorder selected from Alzheimer's disease, amyotrophic lateral sclerosis (ALS), attention deficit hyperactivity disorder, autism, cerebellar ataxia, Charcot-Marie-Tooth disease, Creutzfeldt-Jakob disease, dementia, epilepsy, Friedreich's ataxia, Huntington's disease, multiple sclerosis, obsessive compulsive disorder (OCD), Parkinson's disease, Progressive supranuclear palsy (PSP), Rett syndrome, senile chorea, spinal ataxia, spinal cord injury, and traumatic brain injury. In embodiments, the neurological disease or disorder is dementia. In embodiments, the dementia is selected from AIDS dementia complex (ADC), dementia associated with Alzheimer's disease (AD), dementia pugilistica, diffuse Lewy body disease, frontotemporal dementia, mixed dementia, senile dementia of Lewy body type, and vascular dementia. In embodiments, the neurological disease or disorder is amyotrophic lateral sclerosis (ALS). In embodiments, the neurological disease or disorder is Rett syndrome. In embodiments, the neurological disease or disorder is obsessive compulsive disorder (OCD).

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 : Fold change of plasma (shed) GPNMB after 14 days of dosing between pre-dose and day 15 in 12 patients. The fold change for each patient is indicated parentheses in the key in the upper right corner of the graph.

FIGS. 2A-2B. FIG. 2A is a graph showing weight change in a TDP-43 (rNLS8) mouse model of ALS, from baseline by Group Mean percent baseline body weight (y-axis) for the duration of the study (x-axis) for each of the two treatment groups showing group means (solid lines) and standard deviations (dotted lines). Weights just prior to first dose were used for baseline (Day −3). The dashed vertical line indicates the removal of Full DOX diet (Day 0), and the dotted vertical line indicates the start of Low DOX. ** indicates p<0.01. FIG. 2B is a graph with each subplot shows the mean percent baseline body weight over the first, second, and third week of the study. For each week, group means are represented by the horizontal bar with standard deviation error bars. Each individual animal mean is represented by a triangle (female mice) or a circle (male mice). Statistical results are included in the title text of each subplot. In FIG. 2B, “Tx” represents apilimod dimesylate treated group. A two-way ANOVA showed a highly significant interaction between Group and Time (two-way mixed ANOVA, Group x Time Interaction p<0.0001).

FIGS. 3A-3B. FIG. 3A is a graph showing severity score related to hindlimb clasping over time in vehicle and apilimod treated mice, *** indicates p<0.001. FIG. 3B is a graph showing mean hindlimb clasping scores for each study week. In FIG. 3B, “Tx” represents apilimod dimesylate treated group. Statistical results are included in the title text of each subplot.

FIGS. 4A-4B. FIG. 4A is a graph showing hindlimb paralysis scores (also herein “severity score”) in vehicle and apilimod treated mice. * indicates p<0.05. FIG. 4B is a graph showing mean hindlimb paralysis scores for each study week. In FIG. 4B, “Tx” represents apilimod dimesylate treated group. Statistical results are included in the title text of each subplot.

FIGS. 5A-5B. FIG. 5A is a graph showing grill agility scores (also herein “severity score”) in vehicle and apilimod treated mice. *** indicates p<0.001. FIG. 5B is a graph showing mean grill agility scores for each study week. In FIG. 5B, “Tx” represents apilimod dimesylate treated group. Statistical results are included in the title text of each subplot.

FIGS. 6A-6B. FIG. 6A is a graph showing severity score related to tremor in vehicle and apilimod treated mice. ** indicates p<0.01. FIG. 6B is a graph showing tremor scores for each study week. In FIG. 6B, “Tx” represents apilimod dimesylate treated group. Statistical results are included in the title text of each subplot.

FIGS. 7A-7B. FIG. 7A is a graph showing overall wellbeing score in vehicle and apilimod treated mice. FIG. 7B is a graph showing overall wellbeing score for each study week. In FIG. 7B, “Tx” represents apilimod dimesylate treated group. Statistical results are included in the title text of each subplot.

FIGS. 8A-8B. FIG. 8A is a graph showing composite clinical score in vehicle and apilimod treated mice. *** indicates p<0.001. FIG. 8B is a graph showing composite clinical score for each study week. In FIG. 8B, “Tx” represents apilimod dimesylate treated group. Statistical results are included in the title text of each subplot.

FIGS. 9A-9B. FIG. 9A is a graph showing the concentration of Neurofilament Light (NfL) in CSF and FIG. 9B is a graph showing the concentration of NfL in Blood Plasma (FIG. 9B). Group means for the CSF and plasma concentrations of NfL are represented by the horizontal bar with standard deviation error bars. Each individual animal mean is represented by a triangle (female mice) or a circle (male mice). Statistical results are included in the title text of each subplot. “Tx” represents apilimod dimesylate treated group.

DETAILED DESCRIPTION OF THE DISCLOSURE

The present disclosure provides compositions and methods related to the use of apilimod for treating neurological diseases and disorders, and cancer, particularly in combination with modulators of the glutamate transporter/receptor system. Accordingly, the disclosure provides methods for treating a neurological disease or disorder and methods for treating cancer in a subject in need thereof, comprising administering apilimod, or a pharmaceutically acceptable salt thereof, in combination with a glutamatergic agent.

The present disclosure provides compositions and methods related to the use apilimod for reducing neuromuscular degradation, reducing motor dysfunction, reducing deterioration of muscle strength, reducing deterioration of fine motor skills, maintaining fine motor skills, and/or improving muscle strength in a subject with a neurological disease or disorder that involve administering to the subject an effective amount of apilimod, or a pharmaceutically acceptable salt of apilimod.

The term “apilimod” refers to 2-[2-Pyridin-2-yl)-ethoxy]-4-N′-(3-methyl-benzilidene)-hydrazino]-6-(morpholin-4-yl)-pyrimidine (IUPAC name: (E)-4-(6-(2-(3-methylbenzylidene)hydrazinyl)-2-(2-(pyridin-2-yl)ethoxy)pyrimidin-4-yl)morpholine), represented by Formula I:

The CAS number of apilimod is 541550-19-0.

Apilimod can be prepared, for example, according to the methods described in U.S. Pat. Nos. 7,923,557, and 7,863,270, and WO 2006/128129.

In embodiments of the compositions and methods described here, a pharmaceutically acceptable salt, solvate, clathrate, hydrate, polymorph, metabolite, prodrug, analog or derivative of apilimod may be used in the compositions and methods for treating a neurological disease or disorder.

The term “pharmaceutically acceptable salt,” is a salt formed from, for example, an acid and a basic group of a compound described herein (e.g., 2-[2-Pyridin-2-yl)-ethoxy]-4-N′-(3-methyl-benzilidene)-hydrazino]-6-(morpholin-4-yl)-pyrimidine). Illustrative salts include, but are not limited, to sulfate, citrate, acetate, oxalate, chloride, bromide, iodide, nitrate, bisulfate, phosphate, acid phosphate, isonicotinate, lactate, salicylate, acid citrate, tartrate, oleate, tannate, pantothenate, bitartrate, ascorbate, succinate, maleate, besylate, gentisinate, fumarate, gluconate, glucaronate, saccharate, formate, benzoate, glutamate, methanesulfonate, ethanesulfonate, benzenesulfonate, p-toluenesulfonate, and pamoate (e.g., 1, l′-methylene-bis-(2-hydroxy-3-naphthoate)) salts. In a preferred embodiment, the salt of apilimod comprises methanesulfonate. The term “pharmaceutically acceptable salt” also refers to a salt prepared from a compound described herein (e.g., 2-[2-Pyridin-2-yl)-ethoxy]-4-N′-(3-methyl-benzilidene)-hydrazino]-6-(morpholin-4-yl)-pyrimidine), having an acidic functional group, such as a carboxylic acid functional group, and a pharmaceutically acceptable inorganic or organic base.

Suitable bases include, but are not limited to, hydroxides of alkali metals such as sodium, potassium, and lithium; hydroxides of alkaline earth metal such as calcium and magnesium; hydroxides of other metals, such as aluminum and zinc; ammonia, and organic amines, such as unsubstituted or hydroxy-substituted mono-, di-, or trialkylamines; dicyclohexylamine; tributyl amine; pyridine; N-methyl, N-ethylamine; diethylamine; triethylamine; mono-, bis-, or tris-(2-hydroxy-lower alkyl amines), such as mono-, bis-, or tris-(2-hydroxyethyl)amine, 2-hydroxy-tert-butylamine, or tris-(hydroxymethyl)methylamine, N, N,-di-lower alkyl-N-(hydroxy lower alkyl)-amines, such as N,N-dimethyl-N-(2-hydroxyethyl)amine, or tri-(2-hydroxyethyl)amine; N-methyl-D-glucamine; and amino acids such as arginine, lysine, and the like. The term “pharmaceutically acceptable salt” also refers to a salt prepared from a compound described herein (e.g., 2-[2-Pyridin-2-yl)-ethoxy]-4-N′-(3-methyl-benzilidene)-hydrazino]-6-(morpholin-4-yl)-pyrimidine), having a basic functional group, such as an amino functional group, and a pharmaceutically acceptable inorganic or organic acid. Suitable acids include hydrogen sulfate, citric acid, acetic acid, oxalic acid, hydrochloric acid (HCl), hydrogen bromide (HBr), hydrogen iodide (HI), nitric acid, hydrogen bisulfide, phosphoric acid, lactic acid, salicylic acid, tartaric acid, bitartratic acid, ascorbic acid, succinic acid, maleic acid, besylic acid, fumaric acid, gluconic acid, glucaronic acid, formic acid, benzoic acid, glutamic acid, methanesulfonic acid, ethanesulfonic acid, benzenesulfonic acid, and p-toluenesulfonic acid.

The salts of the compounds described herein (e.g., 2-[2-Pyridin-2-yl)-ethoxy]-4-N′-(3-methyl-benzilidene)-hydrazino]-6-(morpholin-4-yl)-pyrimidine) can be synthesized from the parent compound (e.g., 2-[2-Pyridin-2-yl)-ethoxy]-4-N′-(3-methyl-benzilidene)-hydrazino]-6-(morpholin-4-yl)-pyrimidine) by conventional chemical methods such as methods described in Pharmaceutical Salts: Properties, Selection, and Use, P. Hemrich Stalil (Editor), Camille G. Wermuth (Editor), ISBN: 3-90639-026-8, August 2002. Generally, such salts can be prepared by reacting the parent compound (e.g., 2-[2-Pyridin-2-yl)-ethoxy]-4-N′-(3-methyl-benzilidene)-hydrazino]-6-(morpholin-4-yl)-pyrimidine) with the appropriate acid in water or in an organic solvent, or in a mixture of the two.

One salt form of a compound described herein (e.g., 2-[2-Pyridin-2-yl)-ethoxy]-4-N′-(3-methyl-benzilidene)-hydrazino]-6-(morpholin-4-yl)-pyrimidine) can be converted to the free base and optionally to another salt form by methods well known to the skilled person. For example, the free base can be formed by passing the salt solution through a column containing an amine stationary phase (e.g. a Strata-NH₂ column). Alternatively, a solution of the salt in water can be treated with sodium bicarbonate to decompose the salt and precipitate out the free base. The free base may then be combined with another acid using routine methods.

The term “polymorph” means solid crystalline forms of a compound of the present disclosure (e.g., 2-[2-Pyridin-2-yl)-ethoxy]-4-N′-(3-methyl-benzilidene)-hydrazino]-6-(morpholin-4-yl)-pyrimidine) or complex thereof. Different polymorphs of the same compound can exhibit different physical, chemical and/or spectroscopic properties. Different physical properties include, but are not limited to stability (e.g., to heat or light), compressibility and density (important in formulation and product manufacturing), and dissolution rates (which can affect bioavailability). Differences in stability can result from changes in chemical reactivity (e.g., differential oxidation, such that a dosage form discolors more rapidly when comprised of one polymorph than when comprised of another polymorph) or mechanical characteristics (e.g., tablets crumble on storage as a kinetically favored polymorph converts to thermodynamically more stable polymorph) or both (e.g., tablets of one polymorph are more susceptible to breakdown at high humidity). Different physical properties of polymorphs can affect their processing. For example, one polymorph might be more likely to form solvates or might be more difficult to filter or wash free of impurities than another due to, for example, the shape or size distribution of particles of it.

The term “hydrate” means a compound of the present disclosure (e.g., 2-[2-Pyridin-2-yl)-ethoxy]-4-N′-(3-methyl-benzilidene)-hydrazino]-6-(morpholin-4-yl)-pyrimidine) or a salt thereof, which further includes a stoichiometric or non-stoichiometric amount of water bound by non-covalent intermolecular forces.

The term “clathrate” means a compound of the present disclosure (e.g., 2-[2-Pyridin-2-yl)-ethoxy]-4-N′-(3-methyl-benzilidene)-hydrazino]-6-(morpholin-4-yl)-pyrimidine) or a salt thereof in the form of a crystal lattice that contains spaces (e.g., channels) that have a guest molecule (e.g., a solvent or water) trapped within.

The term “prodrug” means a derivative of a compound described herein (e.g., 2-[2-Pyridin-2-yl)-ethoxy]-4-N′-(3-methyl-benzilidene)-hydrazino]-6-(morpholin-4-yl)-pyrimidine) that can hydrolyze, oxidize, or otherwise react under biological conditions (in vitro or in vivo) to provide a compound of the disclosure. Prodrugs may only become active upon such reaction under biological conditions, or they may have activity in their unreacted forms. Examples of prodrugs contemplated in this disclosure include, but are not limited to, analogs or derivatives of a compound described herein (e.g., 2-[2-Pyridin-2-yl)-ethoxy]-4-N′-(3-methyl-benzilidene)-hydrazino]-6-(morpholin-4-yl)-pyrimidine) that comprise biohydrolyzable moieties such as biohydrolyzable amides, biohydrolyzable esters, biohydrolyzable carbamates, biohydrolyzable carbonates, biohydrolyzable ureides, and biohydrolyzable phosphate analogues. Other examples of prodrugs include derivatives of compounds of any one of the formulae disclosed herein that comprise —NO, —NO₂, —ONO, or —ONO₂ moieties. Prodrugs can typically be prepared using well-known methods, such as those described by Burger's Medicinal Chemistry and Drug Discovery (1995) 172-178, 949-982 (Manfred E. Wolff ed., 5th ed).

In addition, some of the compounds suitable for use in the methods of in this disclosure (e.g., 2-[2-Pyridin-2-yl)-ethoxy]-4-N′-(3-methyl-benzilidene)-hydrazino]-6-(morpholin-4-yl)-pyrimidine) have one or more double bonds, or one or more asymmetric centers. Such compounds can occur as racemates, racemic mixtures, single enantiomers, individual diastereomers, diastereomeric mixtures, and cis- or trans- or E- or Z-double isomeric forms. All such isomeric forms of these compounds are expressly included in the present disclosure. The compounds of this disclosure (e.g., 2-[2-Pyridin-2-yl)-ethoxy]-4-N′-(3-methyl-benzilidene)-hydrazino]-6-(morpholin-4-yl)-pyrimidine) can also be represented in multiple tautomeric forms, in such instances, the disclosure expressly includes all tautomeric forms of the compounds described herein (e.g., there may be a rapid equilibrium of multiple structural forms of a compound), the disclosure expressly includes all such reaction products). All such isomeric forms of such compounds are expressly included in the present disclosure. All crystal forms of the compounds described herein (e.g., 2-[2-Pyridin-2-yl)-ethoxy]-4-N′-(3-methyl-benzilidene)-hydrazino]-6-(morpholin-4-yl)-pyrimidine) are expressly included in the present disclosure.

The term “solvate” or “pharmaceutically acceptable solvate,” is a solvate formed from the association of one or more solvent molecules to one of the compounds disclosed herein (e.g., 2-[2-Pyridin-2-yl)-ethoxy]-4-N′-(3-methyl-benzilidene)-hydrazino]-6-(morpholin-4-yl)-pyrimidine). The term solvate includes hydrates (e.g., hemi-hydrate, mono-hydrate, dihydrate, trihydrate, tetrahydrate, and the like).

The term “analog” refers to a chemical compound that is structurally similar to another but differs slightly in composition (as in the replacement of one atom by an atom of a different element or in the presence of a particular functional group, or the replacement of one functional group by another functional group). Thus, an analog is a compound that is similar or comparable in function and appearance, but not in structure or origin to the reference compound. As used herein, the term “derivative” refers to compounds that have a common core structure and are substituted with various groups as described herein.

In certain embodiments of the disclosure described herein, apilimod, or a pharmaceutically acceptable salt, hydrate, clathrate, or prodrug of apilimod, as described above, may be provided in combination with one or more additional therapeutic agents. In accordance with any of these embodiments, the apilimod, or a pharmaceutically acceptable salt, solvate, clathrate, hydrate, polymorph, metabolite, prodrug, analog or derivative thereof, may be provided in the same dosage form as the one or more additional therapeutic agents, or in a separate dosage form.

Methods of Treatment

The present disclosure provides methods for treating a neurological disease or disorder, or a cancer, in a subject in need thereof comprising administering apilimod, or a pharmaceutically acceptable salt, solvate, clathrate, hydrate, polymorph, metabolite, prodrug, analog or derivative thereof, alone in combination with a glutamatergic agent or another agent. The present disclosure further provides the use of apilimod, or a pharmaceutically acceptable salt, solvate, clathrate, hydrate, polymorph, metabolite, prodrug, analog or derivative thereof, alone or in combination with a glutamatergic agent for the preparation of a medicament useful for the treatment of a neurological disease or disorder, or a cancer.

In some embodiments, neurological diseases or disorders are characterized by degeneration and death of motor neurons, which leads to generalized weakness and muscle atrophy. In some embodiments, in diseases such as ALS, selective death of motor neurons located in the brainstem, motor cortex and spinal cord leading to paralysis of voluntary muscles. The paralysis begins focally and disseminates in a pattern that suggests that degeneration is spreading among contiguous pools of motor neurons. Mortality results when control of the diaphragm is impaired and the ability to breathe is lost. ALS is characterized by progressive manifestations of dysfunction of both lower and upper motor neurons. Lower motor neurons connect the brainstem and spinal cord to muscle fibers and their dysfunction leads to muscle atrophy, cramps and fasciculations (small, local, involuntary muscle contraction). Upper motor neurons originate in motor region of the cerebral cortex or the brainstem and carry motor information down to motor neurons that are directly responsible for stimulating the target muscle and their dysfunction leads to spasticity (continuous muscle contraction that interfere with gait, movement, and speech) and pathological reflexes.

The present disclosure provides a method of reducing neuromuscular degradation, reducing motor dysfunction, reducing deterioration of muscle strength, reducing deterioration of fine motor skills, maintaining fine motor skills, and/or improving muscle strength in a patient with a neurological disease or disorder. Such methods include administering an effective amount of apilimod, or a pharmaceutically acceptable salt thereof, thereby reducing neuromuscular degradation, reducing motor dysfunction, reducing deterioration of muscle strength, reducing deterioration of fine motor skills, maintaining fine motor skills, and/or improving muscle strength in the patient.

In some embodiments, muscle strength of a subject is evaluated using known methods in the art. Quantitative strength measures generally demonstrate a linear, predictable strength loss within a patient. In some embodiments, Tufts Quantitative Neuromuscular Examination (TQNE) is used to provide quantitative measurements using a fixed strain gauge. TQNE measures isometric strength of 20 muscle groups and produces interval strength data in both strong and weak muscles (See e.g., Andres et ah, Neurology 36:937-941, 1986). Hand-held dynamometry (HHD) tests isometric strength of specific muscles in the arms and legs and produces interval level data (See e.g., Shefne J M, Neurotherapeutics 14:154-160, 2017). Accurate Test of Limb Isometric Strength (ATL1S) is used to measure both strong and weak muscle groups using a fixed, wireless load cell (See e.g., Andres et ah, Muscle Nerve 56(4):710715, 2017). Force in twelve muscle groups is evaluated in an ATLIS testing, which reflect the subject's strength in the lower limbs, upper limbs, as well as the subject's grip strength. In some embodiments, ATLIS testing detects changes in muscle strength before any change in function is observed.

In some embodiments, methods provided herein improve, maintain, or slow down the deterioration of a subject's muscle strength (e.g., lower limb strength, upper limb strength, or grip strength), as evaluated by any of the suitable methods described herein. In some embodiments, the methods result in improvement of the subject's upper limb strength more significantly than other muscle groups. For example, the effect on muscle strength can be reflected in one or more muscle groups selected from quadriceps, biceps, hamstrings, triceps, and anterior tibialis.

In some embodiments, the methods provided herein improve or slow down deterioration of a subject's fine motor function. In some embodiments, motor function is evaluated by one or more categories of the ALSFRS-R scale (e.g., handwriting, cutting food and handling utensils, or dressing and hygiene) (see e.g., Berry et al. Amyotroph Lateral Scler Frontotemporal Degener 2014; 15:1-8; Traynor et al., Neurology 63: 1933-1935, 2004; Simon et al., Ann Neurol 76:643-657, 2014; and Moore et al. Amyotroph Lateral Scler Other Motor Neuron Disord 4:42, 2003).

In some embodiments, apilimod or a pharmaceutically acceptable salt thereof can reduce motor dysfunction, deterioration of muscle strength, deterioration of fine motor skills, by about 1-10%, 15-25%, 20-30%, 25-35%, 30-40%, 35-45%, 40-50%, 45-55%, 50-60%, 55-65%, 65-75%, 70-80%, 75-85%, 80-90%, 85-95% or 90-100%.

In some embodiments, apilimod or a pharmaceutically acceptable salt thereof can improve fine motor skills or muscle strength by about 1-10%, 15-25%, 20-30%, 25-35%, 30-40%, 35-45%, 40-50%, 45-55%, 50-60%, 55-65%, 60-70%, 65-75%, 70-80%, 75-85%, 80-90%, or 90-100%.

In some embodiments, apilimod or a pharmaceutically acceptable salt thereof is used in combination with a glutamatergic agent, and/or an antioxidant.

In embodiments, the glutamatergic agent is selected from a glutamate transporter modulating agent and a glutamate receptor antagonist. In embodiments, the glutamate transporter modulating agent is an excitatory amino acid reuptake inhibitor. In embodiments, the glutamate receptor antagonist is an N-methyl-D-aspartate (NMDA) receptor antagonist. In embodiments, the glutamate receptor antagonist is an antagonist of the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPA) receptor, or the kainite receptor.

In embodiments, the glutamatergic agent is a glutamate receptor antagonist selected from AP5 (R-2-amino-5-phosphonopentanoate), AP7 (2-amino-7-phosphonoheptanoic acid), CNQX (6-cyano-7-nitroquinoxaline-2,3-dione), CPPene (3-[(R)-2-carboxypiperazin-4-yl]-prop-2-enyl-1-phosphonic acid), NBQX (2,3-dihydroxy-6-nitro-7-sulfamoyl-benzo[f]quinoxaline-2,3-dione), and selfotel (CGS-19755).

In embodiments, the glutamatergic agent is a glutamate receptor antagonist selected from amantadine, atomoxetine, AZD6765, agmatine, gacyclidine, ketamine, memantine, eliprodil, delucemin.

In embodiments, the glutamatergic agent is selected from BHV-5000, lamotrigine, lanicemine, riluzole, trigriluzole, and topiramate.

In one embodiment, the antioxidant is edaravone (Radicava™, Radicut™).

In some embodiments, the methods described here relate to combination therapy with apilimod and at least one glutamatergic agent. The terms, “combination therapy” or “co-therapy” include the administration of a compound described herein, e.g., apilimod, or a pharmaceutically acceptable salt, solvate, clathrate, hydrate, polymorph, metabolite, prodrug, analog or derivative thereof, with at least one additional agent, e.g., a glutamatergic agent, as part of a specific treatment regimen intended to provide a beneficial effect from the co-action of these compounds. The beneficial effect may result in the slowing of the progression of the neurological disease or disorder, or the cancer, and/or the alleviation of one or more symptoms of the neurological disease or disorder, or the cancer. The beneficial effect of the combination includes, but is not limited to, pharmacokinetic or pharmacodynamic co-action resulting from the combination. The beneficial effect of the combination may also relate to the mitigation of a toxicity, side effect, or adverse event associated with another agent in the combination. “Combination therapy” is not intended to encompass the administration of two or more of these therapeutic compounds as part of separate monotherapy regimens that incidentally and arbitrarily result in the combinations of the present disclosure.

In the context of combination therapy, administration of apilimod, or a pharmaceutically acceptable salt, solvate, clathrate, hydrate, polymorph, metabolite, prodrug, analog or derivative thereof, may be simultaneous with or sequential to the administration of the glutamatergic agent. In another aspect, administration of the different components of a combination therapy may be at different frequencies. The one or more additional agents may be administered prior to (e.g., 5 minutes, 15 minutes, 30 minutes, 45 minutes, 1 hour, 2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, 72 hours, 96 hours, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 8 weeks, or 12 weeks before), concomitantly with, or subsequent to (e.g., 5 minutes, 15 minutes, 30 minutes, 45 minutes, 1 hour, 2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, 72 hours, 96 hours, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 8 weeks, or 12 weeks after) the administration of a compound of the present disclosure.

The therapeutic agents can be formulated for co-administration in a single dosage form, or they can be administered separately in different dosage forms. When administered separately, administration may be by the same or a different route of administration for each of the components of the combination therapy.

Preferably, combination therapy provides a synergistic response. The term “synergistic” refers to the efficacy of the combination being more than the additive effects of either single therapy alone. The synergistic effect of combination therapy may permit the use of lower dosages and/or less frequent administration of at least one agent in the combination compared to its dose and/or frequency outside of the combination. The synergistic effect may also be manifested in the avoidance or reduction of adverse or unwanted side effects associated with the use of either therapy in the combination alone.

In embodiments of the methods described herein, apilimod, or a pharmaceutically acceptable salt, solvate, clathrate, hydrate, polymorph, metabolite, prodrug, analog or derivative thereof, may be administered at the same time or at a different time, the context of the combination therapy with the glutamatergic agent. In embodiments, the apilimod, or a pharmaceutically acceptable salt, solvate, clathrate, hydrate, polymorph, metabolite, prodrug, analog or derivative thereof, and the glutamatergic agent are administered in a single dosage form, or in separate dosage forms.

In embodiments, the combination therapy with apilimod alone or in combination with a glutamatergic agent further includes an additional agent that mitigates one or more side effects of apilimod, for example, nausea, vomiting, headache, dizziness, lightheadedness, drowsiness and stress. In one aspect of this embodiment, the additional agent is a serotonin receptor antagonist, also known as 5-hydroxytryptamine receptors or 5-HT receptors. In one aspect, the additional agent is an antagonist of a 5-HT₃ or 5-HT_(1a) receptor. In one aspect, the agent is selected from the group consisting of ondansetron, granisetron, dolasetron and palonosetron. In another aspect, the agent is selected from the group consisting of pindolol and risperidone.

In accordance with the methods described here, the neurological disease or disorder may be selected from a neurodegenerative disease or disorder, epilepsy, a neuromuscular disorder, or a neurodevelopmental disorder.

Neurodegenerative diseases and disorders that may be treated according to the methods described here include, for example, Alzheimer's disease (AD), amyotrophic lateral sclerosis (ALS), diffuse Lewy body disease, motor neuron diseases, multiple sclerosis (MS), Parkinson's disease (PD), Friedreich's ataxia, prion disease, spinocerebellar ataxia (SCA), and spinal muscular atrophy (SMA). Other, less common neurodegenerative diseases and disorders that may be treated include, for example, Creutzfeldt-Jakob disease (CJD), progressive supranuclear palsy (PSP, Steele-Richardson-Olszewski syndrome), senile chorea, Huntington's Chorea, spinal ataxia including spinocerebellar ataxia (SCA), Friedreich's ataxia, Subacute sclerosing panencephalitis, frontotemporal lobar degeneration, primary lateral sclerosis (PLS), progressive muscular atrophy (PMA), pseudobulbar palsy, progressive bulbar palsy (PBP) and Hallerrorden-Spatz disease (Pantothenate kinase-associated neurodegeneration, PKAN). In an embodiment for the treatment of ALS or frontotemporal dementia, the patient in need of treatment of is one having repeat expansions in the C9ORF72 gene.

Various forms of dementia may also be considered neurodegenerative diseases. In general, the term ‘dementia’ describes a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily functioning. Accordingly, the disclosure also provides methods of treating dementia, including AIDS dementia complex (ADC), dementia associated with Alzheimer's disease (AD), dementia pugilistica, diffuse Lewy body disease, frontotemporal dementia, mixed dementia, senile dementia of Lewy body type, and vascular dementia. In an embodiment for the treatment of frontotemporal dementia, the patient in need of treatment of is one having repeat expansions in the C9ORF72 gene.

Neuromuscular disorders that may be treated according to the methods described here include, for example, infantile spinal muscular atrophy (SMA1, Werdnig-Hoffmann disease), and juvenile spinal muscular atrophy (SMA3, Kugelberg-Welander disease).

Neurodevelopmental disorders that may be treated according to the methods described here include Rett syndrome.

In accordance with the methods described here, the neurological disease or disorder may also be selected from bipolar disorder, treatment resistant and major depression, general anxiety disorder, panic disorder, social anxiety, mood disorders, cognitive disorders, agitation, apathy, psychoses, post-traumatic stress disorders, irritability, disinhibition, learning disorders, memory loss, personality disorders, bipolar disorders, eating disorders, conduct disorder, pain disorders, delirium, drug addiction, tinnitus, mental retardation, cervical spondylotic myelopathy, spinal cord injury, hereditary cerebellar ataxia, Tourette syndrome, autism spectrum disorder, schizophrenia, fragile X syndrome, Parkinson's Disease and Huntington's disease.

In embodiments for the treatment of Alzheimer's disease, the therapy with apilimod alone or in combination with a glutamatergic agent may form part of a therapeutic regimen including administration of a cholinesterase inhibitor (e.g., Aricept™, Exelon™, Razadyne™) In an embodiment for the treatment of Alzheimer's disease, the glutamatergic agent is selected from memantine (Namenda™) and trigriluzole.

In embodiments for the treatment of amyotrophic lateral sclerosis (ALS), the therapy with apilimod alone or in combination with a glutamatergic agent may form part of a therapeutic regimen including administration of an antioxidant, such as edaravone (Radicava™, Radicut™) In an embodiment for the treatment of ALS, the glutamatergic agent is selected from riluzole and trigriluzole. In an embodiment for the treatment of ALS, the glutamatergic agent is trigriluzole. In an embodiment for the treatment of ALS, the patient in need of treatment of is one having repeat expansions in the C9ORF72 gene.

In embodiments for the treatment of obsessive-compulsive disorder (OCD), the therapy with apilimod alone or in combination with a glutamatergic agent may form part of a therapeutic regimen including administration of a selective serotonin reuptake inhibitor (S SRI), clomipramine, or an atypical antipsychotic such as risperidone. In an embodiment for the treatment of ALS, the glutamatergic agent is selected from riluzole and trigriluzole.

In embodiments for the treatment of Rett syndrome, the therapy with apilimod alone or in combination with a glutamatergic agent may form part of a therapeutic regimen including administration of a selective serotonin reuptake inhibitor (S SRI). In an embodiment for the treatment of Rett syndrome, the glutamatergic agent is selected from BHV-5000 and lanicemine.

In embodiments, the disclosure provides a method of treating a neurological disease or disorder selected from stroke, Alzheimer's disease, Parkinson's disease, schizophrenia, epilepsy and chronic pain in a subject in need thereof, the method comprising administering to the subject a pharmaceutical composition comprising apilimod, or a pharmaceutically acceptable salt thereof, optionally apilimod dimesylate, in combination with a glutamatergic agent, optionally selected from agmatine, amantadine, AP5 (R-2-amino-5-phosphonopentanoate), eliprodil, and selfotel.

In embodiments, the disclosure provides a method of treating a neurological syndrome or anxiety-related disorder in a subject in need thereof, the method comprising administering to the subject a pharmaceutical composition comprising apilimod, or a pharmaceutically acceptable salt thereof, optionally apilimod dimesylate, in combination with a glutamatergic agent, optionally selected from AP7 (2-amino-7-phosphonoheptanoic acid) and agmatine.

In embodiments, the disclosure provides a method of treating epilepsy or neuropathic pain in a subject in need thereof, the method comprising administering to the subject a pharmaceutical composition comprising apilimod, or a pharmaceutically acceptable salt thereof, optionally apilimod dimesylate, in combination with a glutamatergic agent, optionally selected from CPPene (3-[(R)-2-carboxypiperazin-4-yl]-prop-2-enyl-1-phosphonic acid), NBQX (2,3-dihydroxy-6-nitro-7-sulfamoyl-benzo[f]quinoxaline-2,3-dione), and selfotel.

In embodiments, the disclosure provides a method of treating Parkinson's disease, Parkinsonism syndrome, or multiple sclerosis in a subject in need thereof, the method comprising administering to the subject a pharmaceutical composition comprising apilimod, or a pharmaceutically acceptable salt thereof, optionally apilimod dimesylate, in combination with a glutamatergic agent, optionally amantadine.

In embodiments, the disclosure provides a method of treating attention deficit hyperactivity disorder (ADHD) in a subject in need thereof, the method comprising administering to the subject a pharmaceutical composition comprising apilimod, or a pharmaceutically acceptable salt thereof, optionally apilimod dimesylate, in combination with a glutamatergic agent, optionally atomoxetine.

In embodiments, the disclosure provides a method of treating depression in a subject in need thereof, the method comprising administering to the subject a pharmaceutical composition comprising apilimod, or a pharmaceutically acceptable salt thereof, optionally apilimod dimesylate, in combination with a glutamatergic agent, optionally selected from agmatine, delucemin, and lanicemine.

In embodiments, the disclosure provides a method of treating cancer in a subject in need thereof, the methods comprising administering to the subject a pharmaceutical composition comprising apilimod, or a pharmaceutically acceptable salt thereof, optionally apilimod dimesylate, in combination with a glutamatergic agent. In embodiments, the cancer expresses the metabotropic glutamate receptor 1 (GRM1). In embodiments, the cancer is an inoperable or metastatic advanced solid tumor or a lymphoma. In embodiments, the cancer is selected from brain cancer (including glioma and glioblastoma), breast cancer, cervical cancer, colorectal cancer, leukemia, lung cancer, lymphoma, melanoma or other skin cancer, ovarian cancer, prostate cancer, renal cancer, and testicular cancer. In embodiments, the cancer is melanoma or breast cancer. In embodiments, the glutamatergic agent is selected from a glutamate transporter modulating agent and a glutamate receptor antagonist. In embodiments, the glutamate transporter modulating agent is an excitatory amino acid reuptake inhibitor. In embodiments, the glutamate receptor antagonist is an N-methyl-D-aspartate (NMDA) receptor antagonist. In embodiments, the glutamate receptor antagonist is selected from AP5 (R-2-amino-5-phosphonopentanoate), AP7 (2-amino-7-phosphonoheptanoic acid), CNQX (6-cyano-7-nitroquinoxaline-2,3-dione), CPPene (3-[(R)-2-carboxypiperazin-4-yl]-prop-2-enyl-1-phosphonic acid), NBQX (2,3-dihydroxy-6-nitro-7-sulfamoyl-benzo[f]quinoxaline-2,3-dione), and selfotel (CGS-19755). In embodiments, the glutamate receptor antagonist is selected from amantadine, atomoxetine, AZD6765, agmatine, gacyclidine, ketamine, memantine, eliprodil, delucemin. In embodiments, the glutamatergic agent is selected from BHV-5000, lamotrigine, lanicemine, riluzole, trigriluzole, and topiramate. In embodiments, the glutamatergic agent is trigriluzole.

A “subject in need thereof” refers to a subject in need of treatment for a neurological disease or disorder, or a cancer. In embodiments, the subject in need is one that is “non-responsive” or “refractory” to a standard therapy for the neurological disease or disorder, or the cancer. In this context, the terms “non-responsive” and “refractory” refer to the subject's response to therapy as not clinically adequate to relieve one or more symptoms associated with the neurological disease or disorder, or the cancer. In embodiments, the patient in need of treatment of is one having repeat expansions in the C9ORF72 gene, for example, in embodiments relating to a neurological disease or disorder, especially ALS or frontotemporal dementia.

A “subject” refers generally to a mammal. The mammal can be e.g., a human, primate, mouse, rat, dog, cat, cow, horse, goat, camel, sheep or a pig. Preferably, the subject is a human. The terms “subject” and “patient” are used interchangeably herein.

The terms, “treatment”, “treating” or “treat” describes the management and care of a subject having a neurological disease or disorder, or a cancer, as described here and includes the administration of a therapeutic agent, or combination thereof as described here, to slow the progression of the disease or disorder and/or to alleviate one or more symptoms of the neurological disease or disorder, or the cancer. In this context, treating includes administering an amount of the therapeutic agent, or combination of agents, effective to alleviate one or more symptoms of the neurological disease or disorder, or the cancer. The term “alleviate” refers to a process by which the severity of a symptom is reduced or decreased, but it may not necessarily be eliminated, although it may be eliminated for a period of time, or temporarily. While elimination of the symptom is preferred, it is not required. The terms, “prevention”, “preventing” or “prevent” refer to reducing or eliminating the onset of a symptom, especially in the context of preventing the progression of the disease or disorder, or the cancer, where progression is defined by the onset one or more symptoms.

The term “therapeutically effective amount” refers to an amount sufficient to treat, ameliorate a symptom of, reduce the severity of, or reduce the duration of the neurological disease or disorder, or the cancer, or to enhance or improve the therapeutic effect of another therapy. The precise effective amount for a subject will depend upon the subject's body weight, size, and health; the nature and extent of the condition; and the therapeutic or combination of therapeutics selected for administration.

An effective amount of apilimod can be administered once daily, from two to five times daily, up to two times or up to three times daily, or up to eight times daily. In embodiments, the apilimod is administered thrice daily, twice daily, once daily, fourteen days on (four times daily, thrice daily or twice daily, or once daily) and 7 days off in a 3-week cycle, up to five or seven days on (four times daily, thrice daily or twice daily, or once daily) and 14-16 days off in 3 week cycle, or once every two days, or once a week, or once every 2 weeks, or once every 3 weeks.

An effective amount of apilimod, or a pharmaceutically acceptable salt, solvate, clathrate, hydrate, polymorph, metabolite, prodrug, analog or derivative thereof, can range from about 0.001 mg/kg to about 1000 mg/kg, more preferably 0.01 mg/kg to about 100 mg/kg, more preferably 0.1 mg/kg to about 10 mg/kg; or any range in which the low end of the range is any amount between 0.001 mg/kg and 900 mg/kg and the upper end of the range is any amount between 0.1 mg/kg and 1000 mg/kg (e.g., 0.005 mg/kg and 200 mg/kg, 0.5 mg/kg and 20 mg/kg). Effective doses will also vary, as recognized by those skilled in the art, depending on the diseases treated, route of administration, excipient usage, and the possibility of co-usage with other therapeutic treatments such as use of other agents. See, e.g., U.S. Pat. No. 7,863,270, incorporated herein by reference.

In more specific aspects, apilimod or a pharmaceutically acceptable salt, solvate, clathrate, hydrate, polymorph, metabolite, prodrug, analog or derivative thereof, is administered at a dosage regimen of 30-300 mg/day (e.g., 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 125, 150, 175, 200, 225, 250, 275, or 300 mg/day) for at least 1 week (e.g., 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 36, 48, or more weeks). Preferably, a compound of the disclosure is administered at a dosage regimen of 100-300 mg/day for 4 or 16 weeks. Alternatively or subsequently, a compound of the disclosure is administered at a dosage regimen of 100 mg twice a day for 8 weeks, or optionally, for 52 weeks.

In some aspects, apilimod or a pharmaceutically acceptable salt, solvate, clathrate, hydrate, polymorph, metabolite, prodrug, analog or derivative thereof, is administered at a dosage regimen of about 30-300 mg/twice a day (BID). In one embodiment, apilimod or a pharmaceutically acceptable salt thereof is administered at a dosage regimen of about 30-100 mg/twice a day, 30-40 mg/twice a day, 35-45 mg/twice a day, 40-50 mg/twice a day, 45-55 mg/twice a day, 50-60 mg/twice a day, 65-75 mg/twice a day, 70-80 mg/twice a day, 75-125 mg/twice a day, 75-85 mg/twice a day, 80-90 mg/twice a day, 85-95 mg/twice a day, 90-100 mg/twice a day, 95-105 mg/twice a day, 100-150 mg/twice a day, 100-110 mg/twice a day, 105-115 mg/twice a day, 110-120 mg/twice a day, 115-125 mg/twice a day, 120-130 mg/twice a day, 125-175 mg/twice a day, 125-135 mg/twice a day, 130-140 mg/twice a day, 135-145 mg/twice a day, 140-150 mg/twice a day, 150-200 mg/twice a day, 175-225 mg/twice a day, 200-250 mg/twice a day, 225-275 mg/twice a day, 250-300 mg/twice a day, or more.

In some aspects, apilimod or a pharmaceutically acceptable salt, solvate, clathrate, hydrate, polymorph, metabolite, prodrug, analog or derivative thereof, is administered at a dosage regimen of about 30 mg/twice a day (BID), 35 mg/twice a day (BID), 40 mg/twice a day (BID), 45 mg/twice a day (BID), 50 mg/twice a day (BID), 55 mg/twice a day (BID), 60 mg/twice a day (BID), 65 mg/twice a day (BID), 70 mg/twice a day (BID), 75 mg/twice a day (BID), 80 mg/twice a day (BID), 85 mg/twice a day (BID), 90 mg/twice a day (BID), 95 mg/twice a day (BID), 100 mg/twice a day (BID), 105 mg/twice a day (BID), 110 mg/twice a day (BID), 115 mg/twice a day (BID), 120 mg/twice a day (BID), 125 mg/twice a day (BID), 130 mg/twice a day (BID), 135 mg/twice a day (BID), 140 mg/twice a day (BID), 145 mg/twice a day (BID), 150 mg/twice a day (BID), 155 mg/twice a day (BID), 160 mg/twice a day (BID), 165 mg/twice a day (BID), 170 mg/twice a day (BID), 175 mg/twice a day (BID), 180 mg/twice a day (BID), 185 mg/twice a day (BID), 190 mg/twice a day (BID), 195 mg/twice a day (BID), 200 mg/twice a day (BID), 205 mg/twice a day (BID), 210 mg/twice a day (BID), 215 mg/twice a day (BID), 220 mg/twice a day (BID), 225 mg/twice a day (BID), 230 mg/twice a day (BID), 235 mg/twice a day (BID), 240 mg/twice a day (BID), 245 mg/twice a day (BID), 250 mg/twice a day (BID), 255 mg/twice a day (BID), 260 mg/twice a day (BID), 265 mg/twice a day (BID), 270 mg/twice a day (BID), 275 mg/twice a day (BID), 280 mg/twice a day (BID), 285 mg/twice a day (BID), 290 mg/twice a day (BID), 295 mg/twice a day (BID), 300 mg/twice a day (BID) or more.

In some aspects, apilimod or a pharmaceutically acceptable salt, solvate, clathrate, hydrate, polymorph, metabolite, prodrug, analog or derivative thereof, is administered at a dosage regimen of about 30-300 mg/three times a day (TID). In one embodiment, apilimod or a pharmaceutically acceptable salt thereof is administered at a dosage regimen of about 30-100 mg/three times a day, 30-40 mg/three times a day, 35-45 mg/three times a day, 40-50 mg/three times a day, 45-55 mg/three times a day, 50-60 mg/three times a day, 65-75 mg/three times a day, 70-80 mg/three times a day, 75-125 mg/three times a day, 75-85 mg/three times a day, 80-mg/three times a day, 85-95 mg/three times a day, 90-100 mg/three times a day, 95-105 mg/three times a day, 100-150 mg/three times a day, 100-110 mg/three times a day, 105-115 mg/three times a day, 110-120 mg/three times a day, 115-125 mg/three times a day, 120-130 mg/three times a day, 125-175 mg/three times a day, 125-135 mg/three times a day, 130-140 mg/three times a day, 135-145 mg/three times a day, 140-150 mg/three times a day, 150-200 mg/three times a day, 175-225 mg/three times a day, 200-250 mg/three times a day, 225-275 mg/three times a day, 250-300 mg/three times a day, or more.

In some aspects, apilimod or a pharmaceutically acceptable salt, solvate, clathrate, hydrate, polymorph, metabolite, prodrug, analog or derivative thereof, is administered at a dosage regimen of about 30 mg/three times a day (TID), 35 mg/three times a day (TID), 40 mg/three times a day (TID), 45 mg/three times a day (TID), 50 mg/three times a day (TID), 55 mg/three times a day (TID), 60 mg/three times a day (TID), 65 mg/three times a day (TID), 70 mg/three times a day (TID), 75 mg/three times a day (TID), 80 mg/three times a day (TID), 85 mg/three times a day (TID), 90 mg/three times a day (TID), 95 mg/three times a day (TID), 100 mg/three times a day (TID), 105 mg/three times a day (TID), 110 mg/three times a day (TID), 115 mg/three times a day (TID), 120 mg/three times a day (TID), 125 mg/three times a day (TID), 130 mg/three times a day (TID), 135 mg/three times a day (TID), 140 mg/three times a day (TID), 145 mg/three times a day (TID), 150 mg/three times a day (TID), 155 mg/three times a day (TID), 160 mg/three times a day (TID), 165 mg/three times a day (TID), 170 mg/three times a day (TID), 175 mg/three times a day (TID), 180 mg/three times a day (TID), 185 mg/three times a day (TID), 190 mg/three times a day (TID), 195 mg/three times a day (TID), 200 mg/three times a day (TID), 205 mg/three times a day (TID), 210 mg/three times a day (TID), 215 mg/three times a day (TID), 220 mg/three times a day (TID), 225 mg/three times a day (TID), 230 mg/three times a day (TID), 235 mg/three times a day (TID), 240 mg/three times a day (TID), 245 mg/three times a day (TID), 250 mg/three times a day (TID), 255 mg/three times a day (TID), 260 mg/three times a day (TID), 265 mg/three times a day (TID), 270 mg/three times a day (TID), 275 mg/three times a day (TID), 280 mg/three times a day (TID), 285 mg/three times a day (TID), 290 mg/three times a day (TID), 295 mg/three times a day (TID), 300 mg/three times a day (TID) or more.

In some embodiments, apilimod is administered for at least 1 week (e.g., 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 36, 48, or more weeks). In one embodiment, the apilimod is administered for 4 or 16 weeks. In one embodiment, a compound of the disclosure is administered at a dosage regimen of 100 mg twice a day, for at least 8 weeks, at least 52 weeks or more. In one embodiment, the apilimod is administered at a dosage regimen of 125 mg twice a day for at least 8 weeks, at least 52 weeks or more. In one embodiment, the apilimod is administered at a dosage regimen of 75 mg twice a day for at least 8 weeks, at least 52 weeks, or more. In one embodiment, the apilimod is administered at a dosage regimen of 125 mg twice a day for the rest of the subject's life. In one embodiment, the apilimod is administered at a dosage regimen of 75 mg twice a day for the rest of the subject's life. In one embodiment, the apilimod is administered at a dosage regimen of 100 mg twice a day for the rest of the subject's life.

Pharmaceutical Compositions and Formulations

The disclosure provides pharmaceutical compositions comprising apilimod, or a pharmaceutically acceptable salt, solvate, clathrate, hydrate, polymorph, metabolite, prodrug, analog or derivative thereof, for use in combination therapy with a glutamatergic agent in the treatment of a neurological disease or disorder, or in the treatment of cancer.

The disclosure also provides pharmaceutical compositions comprising an amount of apilimod, or a pharmaceutically acceptable salt, solvate, clathrate, hydrate, polymorph, metabolite, prodrug, analog or derivative thereof, in combination with a glutamatergic agent and, optionally, at least one pharmaceutically acceptable excipient or carrier, wherein the amount is effective for the treatment of a neurological disease or disorder, or a cancer.

In embodiments, the apilimod, or a pharmaceutically acceptable salt, solvate, clathrate, hydrate, polymorph, metabolite, prodrug, analog or derivative thereof, is combined with a glutamatergic agent in a single dosage form. In embodiments, the pharmaceutical composition further comprises an antioxidant.

A “pharmaceutical composition” is a formulation containing one or more therapeutic agents in a pharmaceutically acceptable form suitable for administration to a subject. The term “pharmaceutically acceptable” refers to those compounds, materials, compositions, carriers, and/or dosage forms which are, within the scope of sound medical judgment, suitable for use in contact with the tissues of human beings and animals without excessive toxicity, irritation, allergic response, or other problem or complication, commensurate with a reasonable benefit/risk ratio.

“Pharmaceutically acceptable excipient” means an excipient that is useful in preparing a pharmaceutical composition that is generally safe, non-toxic and neither biologically nor otherwise undesirable, and includes excipient that is acceptable for veterinary use as well as human pharmaceutical use. Examples of pharmaceutically acceptable excipients include, without limitation, sterile liquids, water, buffered saline, ethanol, polyol (for example, glycerol, propylene glycol, liquid polyethylene glycol and the like), oils, detergents, suspending agents, carbohydrates (e.g., glucose, lactose, sucrose or dextran), antioxidants (e.g., ascorbic acid or glutathione), chelating agents, low molecular weight proteins, or suitable mixtures thereof.

A pharmaceutical composition can be provided in bulk or in dosage unit form. It is especially advantageous to formulate pharmaceutical compositions in dosage unit form for ease of administration and uniformity of dosage. The term “dosage unit form” as used herein refers to physically discrete units suited as unitary dosages for the subject to be treated; each unit containing a predetermined quantity of active compound calculated to produce the desired therapeutic effect in association with the required pharmaceutical carrier. The specification for the dosage unit forms of the disclosure are dictated by and directly dependent on the unique characteristics of the active compound and the particular therapeutic effect to be achieved. A dosage unit form can be an ampoule, a vial, a suppository, a dragee, a tablet, a capsule, an IV bag, or a single pump on an aerosol inhaler.

In therapeutic applications, the dosages vary depending on the agent, the age, weight, and clinical condition of the recipient patient, and the experience and judgment of the clinician or practitioner administering the therapy, among other factors affecting the selected dosage. Generally, the dose should be a therapeutically effective amount. Dosages can be provided in mg/kg/day units of measurement (which dose may be adjusted for the patient's weight in kg, body surface area in m², and age in years). An effective amount of a pharmaceutical composition is that which provides an objectively identifiable improvement as noted by the clinician or other qualified observer. For example, alleviating a symptom of a disorder, disease or condition. As used herein, the term “dosage effective manner” refers to amount of a pharmaceutical composition to produce the desired biological effect in a subject or cell.

For example, the dosage unit form can comprise 1 nanogram to 2 milligrams, or 0.1 milligrams to 2 grams; or from 10 milligrams to 1 gram, or from 50 milligrams to 500 milligrams or from 1 microgram to 20 milligrams; or from 1 microgram to 10 milligrams; or from 0.1 milligrams to 2 milligrams.

The pharmaceutical compositions can take any suitable form (e.g, liquids, aerosols, solutions, inhalants, mists, sprays; or solids, powders, ointments, pastes, creams, lotions, gels, patches and the like) for administration by any desired route (e.g, pulmonary, inhalation, intranasal, oral, buccal, sublingual, parenteral, subcutaneous, intravenous, intramuscular, intraperitoneal, intrapleural, intrathecal, transdermal, transmucosal, rectal, and the like). For example, a pharmaceutical composition of the disclosure may be in the form of an aqueous solution or powder for aerosol administration by inhalation or insufflation (either through the mouth or the nose), in the form of a tablet or capsule for oral administration; in the form of a sterile aqueous solution or dispersion suitable for administration by either direct injection or by addition to sterile infusion fluids for intravenous infusion; or in the form of a lotion, cream, foam, patch, suspension, solution, or suppository for transdermal or transmucosal administration.

A pharmaceutical composition can be in the form of an orally acceptable dosage form including, but not limited to, capsules, tablets, buccal forms, troches, lozenges, and oral liquids in the form of emulsions, aqueous suspensions, dispersions or solutions. Capsules may contain mixtures of a compound of the present disclosure with inert fillers and/or diluents such as the pharmaceutically acceptable starches (e.g., corn, potato or tapioca starch), sugars, artificial sweetening agents, powdered celluloses, such as crystalline and microcrystalline celluloses, flours, gelatins, gums, etc. In the case of tablets for oral use, carriers which are commonly used include lactose and corn starch. Lubricating agents, such as magnesium stearate, can also be added. For oral administration in a capsule form, useful diluents include lactose and dried corn starch. When aqueous suspensions and/or emulsions are administered orally, the compound of the present disclosure may be suspended or dissolved in an oily phase is combined with emulsifying and/or suspending agents. If desired, certain sweetening and/or flavoring and/or coloring agents may be added.

A pharmaceutical composition can be in the form of a tablet. The tablet can comprise a unit dosage of a compound of the present disclosure together with an inert diluent or carrier such as a sugar or sugar alcohol, for example lactose, sucrose, sorbitol or mannitol. The tablet can further comprise a non-sugar derived diluent such as sodium carbonate, calcium phosphate, calcium carbonate, or a cellulose or derivative thereof such as methyl cellulose, ethyl cellulose, hydroxypropyl methyl cellulose, and starches such as corn starch. The tablet can further comprise binding and granulating agents such as polyvinylpyrrolidone, disintegrants (e.g. swellable crosslinked polymers such as crosslinked carboxymethylcellulose), lubricating agents (e.g. stearates), preservatives (e.g. parabens), antioxidants (e.g. BHT), buffering agents (for example phosphate or citrate buffers), and effervescent agents such as citrate/bicarbonate mixtures.

The tablet can be a coated tablet. The coating can be a protective film coating (e.g. a wax or varnish) or a coating designed to control the release of the active agent, for example a delayed release (release of the active after a predetermined lag time following ingestion) or release at a particular location in the gastrointestinal tract. The latter can be achieved, for example, using enteric film coatings such as those sold under the brand name Eudragit®.

Tablet formulations may be made by conventional compression, wet granulation or dry granulation methods and utilize pharmaceutically acceptable diluents, binding agents, lubricants, disintegrants, surface modifying agents (including surfactants), suspending or stabilizing agents, including, but not limited to, magnesium stearate, stearic acid, talc, sodium lauryl sulfate, microcrystalline cellulose, carboxymethylcellulose calcium, polyvinylpyrrolidone, gelatin, alginic acid, acacia gum, xanthan gum, sodium citrate, complex silicates, calcium carbonate, glycine, dextrin, sucrose, sorbitol, dicalcium phosphate, calcium sulfate, lactose, kaolin, mannitol, sodium chloride, talc, dry starches and powdered sugar. Preferred surface modifying agents include nonionic and anionic surface modifying agents. Representative examples of surface modifying agents include, but are not limited to, poloxamer 188, benzalkonium chloride, calcium stearate, cetostearyl alcohol, cetomacrogol emulsifying wax, sorbitan esters, colloidal silicon dioxide, phosphates, sodium dodecylsulfate, magnesium aluminum silicate, and triethanolamine.

A pharmaceutical composition can be in the form of a hard or soft gelatin capsule. In accordance with this formulation, the compound of the present disclosure may be in a solid, semi-solid, or liquid form.

A pharmaceutical composition can be in the form of a sterile aqueous solution or dispersion suitable for parenteral administration. The term parenteral as used herein includes subcutaneous, intracutaneous, intravenous, intramuscular, intra-articular, intraarterial, intrasynovial, intrasternal, intrathecal, intralesional and intracranial injection or infusion techniques.

A pharmaceutical composition can be in the form of a sterile aqueous solution or dispersion suitable for administration by either direct injection or by addition to sterile infusion fluids for intravenous infusion, and comprises a solvent or dispersion medium containing, water, ethanol, a polyol (e.g., glycerol, propylene glycol and liquid polyethylene glycol), suitable mixtures thereof, or one or more vegetable oils. Solutions or suspensions of the compound of the present disclosure as a free base or pharmacologically acceptable salt can be prepared in water suitably mixed with a surfactant. Examples of suitable surfactants are given below. Dispersions can also be prepared, for example, in glycerol, liquid polyethylene glycols and mixtures of the same in oils.

The pharmaceutical compositions for use in the methods of the present disclosure can further comprise one or more additives in addition to any carrier or diluent (such as lactose or mannitol) that is present in the formulation. The one or more additives can comprise or consist of one or more surfactants. Surfactants typically have one or more long aliphatic chains such as fatty acids which enables them to insert directly into the lipid structures of cells to enhance drug penetration and absorption. An empirical parameter commonly used to characterize the relative hydrophilicity and hydrophobicity of surfactants is the hydrophilic-lipophilic balance (“HLB” value). Surfactants with lower HLB values are more hydrophobic, and have greater solubility in oils, while surfactants with higher HLB values are more hydrophilic, and have greater solubility in aqueous solutions. Thus, hydrophilic surfactants are generally considered to be those compounds having an HLB value greater than about 10, and hydrophobic surfactants are generally those having an HLB value less than about 10. However, these HLB values are merely a guide since for many surfactants, the HLB values can differ by as much as about 8 HLB units, depending upon the empirical method chosen to determine the HLB value.

Among the surfactants for use in the compositions of the disclosure are polyethylene glycol (PEG)-fatty acids and PEG-fatty acid mono and diesters, PEG glycerol esters, alcohol-oil transesterification products, polyglyceryl fatty acids, propylene glycol fatty acid esters, sterol and sterol derivatives, polyethylene glycol sorbitan fatty acid esters, polyethylene glycol alkyl ethers, sugar and its derivatives, polyethylene glycol alkyl phenols, polyoxyethylene-polyoxypropylene (POE-POP) block copolymers, sorbitan fatty acid esters, ionic surfactants, fat-soluble vitamins and their salts, water-soluble vitamins and their amphiphilic derivatives, amino acids and their salts, and organic acids and their esters and anhydrides.

The present disclosure also provides packaging and kits comprising pharmaceutical compositions for use in the methods of the present disclosure. The kit can comprise one or more containers selected from the group consisting of a bottle, a vial, an ampoule, a blister pack, and a syringe. The kit can further include one or more of instructions for use in treating and/or preventing a disease, condition or disorder of the present disclosure, one or more syringes, one or more applicators, or a sterile solution suitable for reconstituting a pharmaceutical composition of the present disclosure.

All percentages and ratios used herein, unless otherwise indicated, are by weight. Other features and advantages of the present disclosure are apparent from the different examples. The provided examples illustrate different components and methodology useful in practicing the present disclosure. The examples do not limit the claimed disclosure. Based on the present disclosure the skilled artisan can identify and employ other components and methodology useful for practicing the present disclosure.

Example 1

In patients treated with apilimod there are alterations in various proteins circulating in the blood plasma. One of these is Glycoprotein Nonmetastatic Melanoma Protein B (GPNMB), a type I membrane protein originally identified in melanoma cells. In addition to expression on the cell surface, it can also be released (or shed) from cells by the activity of matrix metalloproteases such as ADAM10 and ADAM12.

Expression of GPNMB increases significantly in the spinal cords of patients with ALS and this is accompanied by an increase in shed GPNMB in sera. A mouse model, which is based on the known mutation of Superoxide Dismutase 1 (SOD1^(G93A)) found in familial cases of ALS replicates, many of the features of the human disease including the increase in GPNMB. In this model, further increasing the levels of GPNMB prolongs survival, delays onset, and protects skeletal muscle from denervation and atrophy. The effects of GPNMB are likely mediated through the extracellular, shed form of GPNMB, since the latter can directly attenuate SOD1^(G93A) induced neural cell death in culture, as reported previously in Nagahara et al. (2016) J. Neuroscience. Neuroprotective effects have also been demonstrated in a mutant transactive response DNA binding protein 43 kDa (TDP-43) cell culture model suggesting protection across ALS predisposing mutations.

Accordingly, we investigated whether apilimod treatment in humans increased the levels of shed GPNMB.

A SOMAscan™ platform was used to identify analytes that were changed in the plasma of patients upon apilimod dosing. SOMAscan™ is an aptamer-based proteomics assay from SomaLogic capable of measuring 1,305 human protein analytes in serum or plasma with high sensitivity and specificity. Plasma from patients enrolled in the clinical trial designated NCT02594384 was collected pre-dose (before the first administration of apilimod) and after 14 days of dosing with apilimod, on day 15. Using differential protein analysis with a paired experimental design for linear models of microarray data using the “Limma R” software package described by Ritchie et al. in Nucleic Acids Research, 43(7), pp. e47 (2015).

GPNMB was identified as the analyte that showed the highest average fold change (4-fold) among the analytes that were significantly changed (FDR<0.05) (FIG. 1 ). Thus, apilimod dosing consistently increased the plasma levels of GPNMB in treated patients. These results indicate that apilimod treatment may ameliorate the neuromuscular degradation found in ALS, and potentially improve patient survival. In addition, since riluzole and/or antioxidants, such as edaravone (Radicava™, Radicut™) are the current standard of care treatment for ALS, we anticipate that combination therapy with apilimod and riluzole or apilimod with edaravone will provide significant improvements in the treatment of ALS compared to apilimod, edaravone or riluzole therapy alone.

Example 2

Experimental Cohorts and Timelines

The primary objective of this Example is to evaluate the efficacy of apilimod dimesylate in a mouse model of ALS using clinical assessment and Simoa analysis of plasma and CSF samples.

For the evaluation, all mice received either apilimod dimesylate (60 mg/kg)) or vehicle two times daily for 24 days, starting at −10 weeks of age, 3 days prior to disease initiation. Both groups had routine clinical assessments 3 times per week. Twenty-four (24) total mice were assigned to one of two groups, as outlined in Table 1.

TABLE 1 Study design Geno- Final N Group type TX Dosing Target N (F/M) A rNLS8 BID (Vehicle) 10 + 2 extra 11 (4F/7M) B rNLS8 BID (Apilimod 10 + 2 extra 12 (6F/6M) dimesylate 60 mg/kg)

Animal Preparation

Transgenic (Tg) rNLS8 (mixed male and female, were used for this study. The TDP-43 (rNLS8) is an ALS animal model. Tg mice were generated by breeding [B6;C3-Tg(tetO-TARDBP*)4V1e/J] mice expressing mutant hTDP-43-ΔNLS with [B6;C3-Tg(NEFH-tTA)8V1e/J] mice directing tTA expression using the human neurofilament heavy polypeptide promoter, creating “Tet-Off” offspring. These mice harbor a human TDP-43 with a defective nuclear localization signal (NLS) whose expression can be suppressed by doxycycline (DOX). Mice are provided DOX containing food during breeding and for first 8 weeks-of-life. Disease is initiated by removal of DOX containing food. Genotypes were confirmed by PCR analysis of ear punch DNA prior to randomizing into experimental groups. For the duration of the study, mice were housed at standard room temperature (maintained at 21±3° C.) with standard humidity (maintained at 50%±20%) and with free access to food and water. During breeding and for the first weeks-of-life, the animals were maintained on a doxycycline (DOX) diet. At 10 (±1) weeks, disease induction began by removal of the DOX diet (including a complete cage change). After 1 week, the animals were given an intermittent low dose of DOX diet (“Low DOX”) to extend the timing of clinical deterioration.

Clinical Assessment

Clinical assessment included measuring body weight and signs of motor dysfunction. Signs of motor dysfunction included tremor, hindlimb clasping, hindlimb paralysis, grill agility, and overall well-being.

Animals were weighed at the beginning of the experiment, and then, for dosing, daily for the duration of the study. Animals were also monitored daily, and clinical assessments were performed three times per week (Mondays, Wednesday, and Fridays) from disease initiation to the end of the study. Each clinical assessment day, animals were assessed for signs of motor dysfunction, including signs of tremor, hindlimb clasping, hindlimb paralysis, grill agility, and overall well-being. Each of these signs were scored on a scale of 0-3: normal/no dysfunction (0), mild (1), moderate (2), or severe (3), as summarized in Table 2.

TABLE 2 Clinical Monitoring Scoring Hindlimb Hindlimb Grill Overall Score Tremor Clasping Paralysis Agility Well-being 0 No sign Normal Normal No Active, of splay gait errors alert, well tremor groomed 1 Subtle Partial Slow or Limbs Slightly signs of retraction wobbly repeatedly hunched tremor without gait, slip, quick and/or (on touching subtle correction scruffy and off) dragging appearance 2 Clear Retracted, Toes curl Constant Hunched, tremor legs down- errors, decreased present, touching wards delayed exploration, more abdomen and/or correction agitated frequent but not clear, each other prolonged dragging 3 Severe, Limbs fully Hindlimb Cannot Inactive, dis- clasped is not pull dehydrated, ruptive and used for limbs piloerection, shaking touching the forward back up sunken abdomen motion to grill eyes

Dosing

Details for each of the treatment groups are provided in Table 3. Apilimod dimesylate was received at ambient temperature in a 50 mL tube and protected from light. The treatments were administered p.o. twice per day (BID) for a period of 24 days Each daily dose was performed within the same ˜2-hour time frame, with approximately 6 hours between doses.

TABLE 3 Treatments. Treatment Vehicle Control Apilimod Formulation Methyl Cellulose 0.5% Concentration n/a 60 mg/kg Dose 10 mL/kg 10 mL/kg Administration 10 μL/g b.w. 10 μL/g b.w. Volume

Cerebrospinal Fluid (CSF) Collection

At the terminal time point, CSF was collected from all animals. Animals were deeply anesthetized with Avertin (500 mg/kg) and placed in the prone position, with the head and body at a 120° angle. The skin and muscle at the nape of the neck were retracted. A 33 G needle and Hamilton syringe was used to pierce the dura matter at the site of the cisterna magna, and CSF was collected by capillary action. CSF (5-10 μL) was transferred to 0.2 mL low bind microcentrifuge tubes, centrifuged to check for blood contamination (packed red blood cells), and frozen at −80° C. The CSF was stored at −80° C.

Terminal Blood Collection and Plasma Preparation

Blood collection and plasma preparation was performed for all study mice at the study endpoint, following CSF collection. Briefly, blood was collected from the descending vena cava of each animal using a SMonovette EDTA collection tube and a multifly 23 G needle (Sarstedt). The blood samples were processed by centrifugation at approximately 5° C. (3000×g, 15 min) within 30 min after collection. The supernatant was then collected and stored at −80° C.

Statistical Analysis

All summary statistics are presented as mean and standard deviation. Statistical analyses were performed in MATLAB. The data were first assessed for normality with a normal probability plot, followed by assessment of homogeneity of variance, if appropriate. As there were only two treatment groups, groups were compared using two-sample t-test (ttest2) or, for nonnormally distributed clinical data, using Mann-Whitney (ranksum). For change in body weight measures, a two-way mixed ANOVA was also used to investigate any interaction between group and timepoint. To clearly illustrate the evolution of weight and clinical scores, and figures are presented using a 3-day moving average. Statistical analyses performed for each visit day were performed on the raw, non-smoothed data.

Animals

No adverse effects of treatment with apilimod were observed, and all but one animal (N=23, 13M/10F) completed the study. The mice were 9.8±0.9 weeks old at the time of first dose with average baseline body weight of 28.1±4.4 g (females 25.1±3.1 g, males 30.5±3.9 g). There were no differences in weight across groups or cohorts at the time of first dose (t-test, p≥0.35).

Changes in Body Weight

As shown in FIG. 2A, immediately after the first dose, the vehicle control group (Group A) lost some weight, while the apilimod treatment group (Group B) tended to gain weight up until Full DOX removal. Once the full DOX diet was removed, both groups, on average, tended to lose weight during the first few days. Group A then slowly regained weight, while Group B slowly continued to lose weight. A two-way ANOVA showed a highly significant Interaction between Group and Time (two-way mixed ANOVA, Group x Time Interaction p<0.0001). Briefly, in Group A, weights for the first two days (pre-dosing Day −3 and Day −2) were significantly higher compared to Day 2 onwards (Simple Main Effect for Time, post hoc for Group A, Day −3 vs. Days 2 to 20, p≤0.0002; Day −2 vs. Days 2 to 20, p≤0.01). On the other hand, in Group B, Day −3 percent baseline weight (i.e., 100%) was not significantly different from any other visit (Simple Main Effect for Time, post hoc for Group B, Day −3 vs. Days −2 to 20, p≥0.53), and Day −2 was only significantly higher compared to Days 3 to 8 (Simple Main Effect for Time, post hoc for Group B, Day −2 vs. Days 3 to 8, p≤0.04). At every clinical assessment visit, there was a tendency for higher percent baseline body weight in Group B compared to Group A, and at most visits this difference reached statistical significance, and the remaining visits trending higher, as detailed in Table 4. Results (p-values) of a two-sample t-test (percent baseline body weight) or Mann-Whitney test (clinical scores) to compare the two treatment groups at each clinical assessment visit.

TABLE 4 Statistical Results for Weight and Clinical Scores. Day off % BL Hindlimb Grill Well- Composite Visit Full Dox Weight Clasping Paralysis Agility Tremor being score 1 0 0.002 n/a n/a n/a n/a n/a n/a 2 1 0.006 0.468 0.113 0.579 0.061 0.338 0.114 3 4 0.039 0.510 0.274 0.251 0.022 0.148 0.030 4 6 0.077 0.728 0.091 0.923 0.012 0.338 0.056 5 8 0.086 0.004 0.579 0.065 0.008 0.338 0.003 6 11 0.109 0.073 0.045 0.345 0.123 0.338 0.048 7 13 0.021 0.033 0.091 0.600 0.082 0.066 0.022 8 15 0.010 0.004 0.017 0.015 0.011 0.239 0.002 9 18 0.002 0.003 0.022 0.006 0.026 0.915 0.003 10 20 0.003 0.001 0.037 <0.001 0.004 0.705 <0.001

When change in weight was averaged across each of the three weeks, group differences again were either significantly higher, or trended higher, in Group B (p≤0.10, see FIG. 2B).

Clinical Progression

Progression of clinical scores (also herein “severity score”) throughout the study, following removal of Full DOX was evaluated. To address day-to-day variability in scoring, each animal's averaged scores during the first week (Days 1-6), second week (Days 8-13), and week (Days 15-20) were also calculated. While both groups showed progression of clinical scores over the three weeks, Group A consistently tended towards more rapid progression and more severe clinical signs compared to Group B.

Hindlimb Clasping

On average, all groups slowly developed signs of mild to moderate clasping over the first two weeks off Full DOX diet (FIG. 3A and FIG. 3B). Group A continued to progress towards more severe clasping, while Group B leveled off. Mann-Whitney tests at each visit showed a significant group difference at several of the later visits, as detailed in Table 4. Weekly averages (FIG. 3B) further showed that Group B had significantly less severe clasping scores at both Week 2 (p=0.02) and Week 3 (p=0.001).

Hindlimb Paralysis

As shown in FIG. 4A and FIG. 4B, both groups slowly developed mild signs of hindlimb paralysis. While the group differences were not as pronounced as for hindlimb clasping, Group A still tended to have higher hindlimb paralysis scores (also herein “severity score”) compared to Group B, and the differences reached significance at a number of the later visits (see Table 4). The week-to-week average scores, shown in FIG. 4B, similarly trended lower in Group B for the first two weeks (p≤0.10), and were significantly lower in Group B at the final week (p=0.015).

Grill Agility

Both groups also developed mild to moderate impairment walking across the cage grill (FIG. 5A and FIG. 5B). During the first week, the two groups progressed similarly. However, compared to hindlimb paralysis, a larger difference developed between the two groups at the final two visits (compare p values for Day 18 and Day 20 in Table 4). Likewise, weekly average scores for grill agility for Week 1 and Week 2 did not show a group difference (p≥0.24), but the difference at Week 3 was highly significant (p=0.001).

Tremor

As shown in FIG. 6A and FIG. 6B, both groups developed tremor, but Group A progressed more rapidly over the first week off Full DOX. Group A had significantly worse tremor scores (also herein “severity score”) at most visits, and for each of the 3 weekly averages (see Table 4 and FIG. 6B).

Overall Well-being

Scores for overall well-being are shown in FIG. 7A and FIG. 7B. Very few mice showed any signs of distress or discomfort over the course of the study, with “scruffy appearance” being the most common observation. While Group A did tend to score higher at earlier visits (see FIG. 7A), the group differences did not reach significance at any visit (p≥0.07, Table 4) or any averaged week (p≥0.07, FIG. 7B).

Composite Clinical Score

For each animal, a composite score was calculated by summing each of the 5 individual measures (clasping, hindlimb paralysis, grill agility, tremor, and overall well-being). As shown in FIG. 8A and FIG. 8B, the composite or cumulative scores reflected the consistent trend of higher clinical scores in Group A compared to Group B throughout the study. Mann-Whitney tests at each visit were significant at every visit except Day 1 and Day 6 (see Table 4). The weekly averages were also significant higher in Group A at every week (p≤0.02, FIG. 8B). Overall, the change in body weight and clinical scores showed a clear tendency for Group B to do better on average compared to Group A. Taken together, these studies show that apilimod ameliorates functional deficits in TDP-43 ALS animal model. Simoa Analysis of Plasma and CSF Samples

CSF samples were successfully collected in all mice that completed the study (N=23). Plasma samples were successfully collected in all mice (N=24), but two mice (including the mouse that did not complete the study) did not have sufficient plasma volume for analysis. Therefore, in total, 23 CSF samples and 22 plasma samples were analyzed for concentration of neurofilament-light polypeptide (NfL) using Simoa assay.

The dilution-corrected concentration levels of NfL in CSF and in plasma are shown in FIG. 9 . In the CSF (FIG. 9A), NfL levels were much higher in Group A compared to Group B, and the statistical results were highly significant (p<0.00001). Except for one outlier in Group B, the individual mice in Group A were all higher than the individual mice in Group B. In plasma (FIG. 9B), NfL levels were also significantly higher in Group A compared to Group B (p=0.03). 

What is claimed is:
 1. A method of reducing neuromuscular degradation, reducing motor dysfunction, reducing deterioration of muscle strength, reducing deterioration of fine motor skills, maintaining fine motor skills, and/or improving muscle strength in a patient with a neurological disease or disorder comprising administering to the patient, an effective amount of apilimod, or a pharmaceutically acceptable salt thereof, thereby reducing neuromuscular degradation, reducing motor dysfunction, reducing deterioration of muscle strength, reducing deterioration of fine motor skills, maintaining fine motor skills, and/or improving muscle strength in the patient.
 2. The method of claim 1, wherein the apilimod is apilimod dimesylate.
 3. The method of claim 1, wherein the apilimod is administered at a dose of about 75 mg to 125 mg twice daily (BID).
 4. The method of claim 3, wherein the apilimod is administered at a dose of about 125 mg BID.
 5. The method of claim 3, wherein the apilimod is administered at a dose of about 100 mg, two times a day (BID).
 6. The method of claim 3, wherein the apilimod is administered at a dose of about 75 mg two times a day (BID).
 7. The method of claim 1, wherein the apilimod, or a pharmaceutically acceptable salt thereof is in an oral dosage form or a sublingual dosage form.
 8. The method of claim 1, wherein the neurological disease or disorder is selected from amyotrophic lateral sclerosis (ALS), Alzheimer's disease, attention deficit hyperactivity disorder, autism, cerebellar ataxia, Charcot-Marie-Tooth disease, Creutzfeldt-Jakob disease, dementia, epilepsy, Friedreich's ataxia, Huntington's disease, multiple sclerosis, obsessive compulsive disorder (OCD), Parkinson's disease, progressive supranuclear palsy, Rett syndrome, senile chorea, spinal ataxia, spinal cord injury, and traumatic brain injury.
 9. The method of claim 1, further comprising administering an effective amount of a glutamatergic agent or an antioxidant.
 10. The method of claim 9, wherein the glutamatergic agent is selected from a glutamate transporter modulating agent and a glutamate receptor antagonist.
 11. The method of claim 10, wherein the glutamate transporter modulating agent is an excitatory amino acid reuptake inhibitor.
 12. The method of claim 10, wherein the glutamate receptor antagonist is an N-methyl-D-aspartate (NMDA) receptor antagonist.
 13. The method of claim 10, wherein the glutamate receptor antagonist is selected from AP5 (R-2-amino-5-phosphonopentanoate), AP7 (2-amino-7-phosphonoheptanoic acid), CNQX (6-cyano-7-nitroquinoxaline-2,3-dione), CPPene (3-[(R)-2-carboxypiperazin-4-yl]-prop-2-enyl-1-phosphonic acid), NBQX (2,3-dihydroxy-6-nitro-7-sulfamoyl-benzo[f]quinoxaline-2,3-dione), and selfotel (CGS-19755).
 14. The method of claim 10, wherein the glutamate receptor antagonist is selected from amantadine, atomoxetine, AZD6765, agmatine, gacyclidine, ketamine, memantine, eliprodil, and delucemin.
 15. The method of claim 9, wherein the glutamatergic agent is selected from BHV-5000, lamotrigine, lanicemine, riluzole, trigriluzole, and topiramate.
 16. The method of claim 9, wherein the antioxidant is edaravone, vitamin E, vitamin C, beta-carotene or a combination thereof.
 17. The method of claim 8, wherein the neurological disease or disorder is ALS. 